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Oral Disease - Hard tissue > Cysts > Flashcards

Cysts Flashcards

1
Q

Define: cyst

A

Pathological cavity (usually epithelial lined) containing fluid, semi-fluid or gas that is not produced by the accumulation of pus

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2
Q

Describe the lining of cysts

A
  • Continuous epithelial lining
  • Discontinuous epithelial lining
  • No epithelial lining
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3
Q

How do the majority of odontogenic cysts grow? What is the significance?

A

Hydrostatic mechanisms

Results in the round shape

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4
Q

How do OKC grow?

A

Through the medullary bone

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5
Q

What is required for a cyst to grow?

A
  • Source of epithelium
  • Proliferative stimulus
  • Mechanism for growth
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6
Q

Define: odontogenic cyst

A

Cyst lined by epithelium dervied from odontogenic epithelium

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7
Q

Define: non-odontogenic cyst

A

Cyst lined by epithelium that is non-odontogenic in origin

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8
Q

Define: Inflammatory cyst

A

Inflammation is the stimulus causing epithelial proliferation and cyst formation

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9
Q

Define: developmental cyst

A

Where aetiology is unknown and deemed developmental

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10
Q

Epithelial source for radicular and residual cysts

A

Cell rests of Malassez

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11
Q

Epithelial source for dentigerous cysts and eruption cysts

A

Reduced enamel epithelium

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12
Q

Epithelial source for OKC, lateral periodontal cyst

A

Cell rests of Serres (remnants of the dental lamina)

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13
Q

List the odontogenic developmental cysts

A 
OKC 
Dentigerous cyst 
Lateral periodontal cyst 
Eruption cyst 
Glandular odontogenic cyst 
Gingival cyst
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14
Q

List the odontogenic inflammatory cysts

A

Radicular cyst
Residual cyst
Paradental cyst

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15
Q

Which cysts are non-odontogenic?

A

Nasopalatine

Nasolabial

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16
Q

Presentation of cysts

A
  • Compressible swelling if large
  • Displacement or loose teeth
  • If infected - similar symptoms to abscess (pain, discharge)
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17
Q

How does swelling occur with cysts?

A

Cyst expands through the normal anatomical boundaries of bone

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18
Q

Where is the swelling of cysts usually located?

A

Buccal or palatal in maxilla

Buccal in mandible (rare in lingual as it is thicker than buccal)

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19
Q

What are the characteristic clinical signs of cysts

A
  • Eggshell cracking
  • Bluish colour of mucosa
  • Fluctuation
  • Discharge of colourless fluid (cholesterol crystals)
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20
Q

What is eggshell cracking? How does it occur?

A

Continued resorption and bony expansion results in a thin layer of bone around the cyst which is easily broken on palpation

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21
Q

What is fluctuation?

A

Pushing the swelling on one side and feeling the transmission of pressure on the other side

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22
Q

What does fluctuation indicate?

A

The lesion is fluid filled

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23
Q

What proportion of patients with cysts have no symptoms

A

1/3 are asymptomatic and found by chance on radiograph

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24
Q

How may a cyst be detected during rct?

A

Inability to dry canals with paper points, could be due to cholesterol clefts indicating a cyst

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25
Q

List the investigations for cysts

A

Vitality testing of nearby teeth
Radiographs
Biopsies to confirm diagnosis
Aspiration?

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26
Q

List the histological features of INFLAMMATORY cysts

A
  • Non-keratinised stratified epithelial lining
  • Thick fibrous wall
  • Inflammation markers present
  • Cholesterol clefts
  • Hyaline bodies
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27
Q

How do cysts resorb bone?

A
  • The cyst itself does not resorb, instead the cyst/inflammatory mediators induces osteoclast activation
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28
Q

How fast do cysts grow on average?

A

Slow - 2cm in 10 years

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29
Q

How fast do cysts grow in children and why?

A

Faster - 5cm in 2 years

Due to less dense bone and quicker turnover

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30
Q

Frequency of radicular cysts

A

70%

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31
Q

Frequency of dentigerous cysts

A

15-20%

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32
Q

Frequency of OKC

A

3-5%

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33
Q

Define radicular cyst

A

Inflammatory cyst that develops from cell rest of Malassez stimulated to proliferate via inflammatory process arising from pulpal necrosis

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34
Q

Describe the lining of radicular cysts

A

Non-keratinised, squamous epithelium

May be discontinuous if replaced by granulation tissue or mural cholesterol nodules

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35
Q

What histological features are associated with radicular cysts

A
  • Acute and chronic inflammatory cells
  • Cholesterol clefts
  • Foamy macrophages
  • Hemosiderin
  • Rushton’s bodies
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36
Q

Where are radicular cysts commonly found

A

Apex of non-vital tooth
Upper laterals common
Anterior maxilla > mandible

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37
Q

Describe the radiographic appearance of radicular cysts

A
  • Size - 1.5-3cm dia
  • Shape - round, unilocular
  • Outline - smooth, well corticated if long standing and may be continous with lamina dura
  • Uniformy radiolucent
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38
Q

What effects do radicular cysts and residual cysts have on adjacent structures

A

Displaced adjacent teeth (Rarely resorbed)
Buccal expansion
Displacement of antrum

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39
Q

Difference between the radiographic appearance of radicular cysts and apical granuloma

A
  • Cysts have corticated margins, whereas granuloma does not
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40
Q

Define a residual radicular cyst

A

Remnant of a radicular cyst after the causative tooth has been extracted

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41
Q

How do residual cysts grow?

A

Via osmotic pressure - however it is very low as the tooth is not there

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42
Q

Where are residual cysts found?

A

Apical regions of an edentulous area in a tooth bearing region
Usually mandibular premolar area

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43
Q

Describe radiographic appearance of residual cysts

A
  • Size - 2-3mm dia
  • Shape - round, unilocular
  • Outline - smooth, well-defined and well corticated margins
  • Uniformly radiolucent
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44
Q

Define dentigerous cysts

A

Cyst developing from the remnants of the reduced enamel epithelium after the tooth has formed

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45
Q

What features does a cyst need in order to be dentigerous?

A
  • Must contain the crown of the unerupted tooth

- Epithelial lining of the cyst is attached to the CEJ of the unerupted tooth

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46
Q

Describe the lining of dentigerous cysts

A

Cuboidal or squmous epithelial lining

May have mucous cells or focal areas of keratinisation of superficial layers

47
Q

Where are dentigerous cysts found?

A

Associated with the crown of unerupted and/or displaced tooth - classically 3s, 5s or 8s

48
Q

Describe the radiographic appearance of a dentigerous cysts

A
  • Size - variable - can be small or can extend up the ramus
  • Shape - round or oval, unilocular, typically envelops crown symmetrically
  • Uniformly radiolucent
49
Q

Effects of dentigerous cysts

A
  • Associated tooth unerupted and idsplaced
  • Adj eeth displaced, resorbed or enveloped
  • Buccal and mesial expansion
  • Displace antrum and ID canal
50
Q

What is a false dentigerous relationship

A

Large cysts that envelop a tooth may be mistaken for dentigerous cysts

51
Q

Define odontogenic keratocyst

A

Cyst arising from the cell rest of Serres due to traumatic implantaion of down growth of the basal cell layer of surface epithelium or REE of the dental follicle

52
Q

What is the difficulty of treating mulilocular cysts e.g. OKC?

A

They have a tendency to recur

53
Q

Describe the lining of OKC

A

Continuous and even layer of keratinised stratified squamous epithelium

Often parakeratinised, but sometimes orthokeratinised

54
Q

Describe the basal cell layer in OKC

A

Well defined with cuboidal or columnar cells displaying palisading

55
Q

What is the lumen of OKC filled with

A

Shed squames and fibrous tissue in the capsule

56
Q

How can characteristic features be lost in OKC

A

Due to inflammation

57
Q

Where are OKC found?

A

Posterior border/angle of the mandible (where 8s are)

May occur in anterior maxilla

58
Q

Why are OKC found posterior mandible

A

8s are the last teeth to erupt therefore this is where the cell rests remain

59
Q

Describe the radiographic appearance of OKC

A

Size - varies, can become extensive

  • Shape - oval, extends along body of mandible and can be unilocular, multilocualr or pseudolocular
  • Outline - smooth if unilocular, scalloped if multilocular, corticated and can be well or poorly defined
60
Q

How is multilocularity determined

A

Bony septa between the locules

61
Q

Describe the effects of OKC

A
  • Minimal displacement and rarely resorbs adj teeth
  • Extensive expansion within cancellous bone (not lingual or buccal)
  • Cortical perforation
  • May envelop crowns of lower 8s (false dentigerous)
62
Q

How do OKC grow

A

Via high mitotic activity in the lining which secretes bone resorbing factors, thus burrowing it along the path of least resistance

63
Q

What is the growth of OKC similar to

A

Ameloblastoma and giant cell lesion

64
Q

Differentiating between OKC and ameloblastoma

A

Ameloblastoma can dispalce, resorb teeth and expand jaw - OKC does not

65
Q

Define the aetiology of basal cell naevus syndrome (Gorlins)

A

Autosomal dominant or sporadic mutation of the patched gene

66
Q

What is the significance of the patched gene

A

Developmental patterning of face and skeleton

Tumour suppression via hedgehog signalling pathway

67
Q

Clinical features of basal cell naevus syndrome

A
  • Multiple OKC
  • Multiple basal cell carcinomas that may ulcerate
  • Bifid, fused and supernumerary ribs
  • Frontal bossing
  • Skeletal class 3
68
Q

Describe lateral periodontal cyst

A

Cyst in the periodontal region that is not inflammatory or an atypical OKC

69
Q

How can biopsy confirm lateral periodontal cyst

A

Two plauqes/thickenings in the epithelial lining

70
Q

Where are lateral periodontal cysts located

A

Lateral surface of the roots of vital teeth

Usually lower canine/premolar or upper laterals

71
Q

Describe radiographic appearance of lateral periodontal cysts

A
  • Small <1mm
  • Shape - unilocular, round
  • Outline - smooth, well defined and corticated
  • Uniformly radiolucent
72
Q

What are the effects of lateral periodontal cyst

A

If large, it can displace adjacent teeth
Buccal expansion
Tooth remains vital

73
Q

Define botryoid odontogenic cyst

A

They are the multilocular variant of lateral periodontal cyst

74
Q

Define paradental cyst

A

Inflammatory cyst arising from the epithelium near the furcation of molars often due to pericoronitis/inflammation

75
Q

What are paradental cysts also called

A

Inflammatory collateral cysts

76
Q

Describe nasopalatine cysts

A

Most common non-odontogenic cyst, it is developmental in origin and arises from epithelium in the incisive canal

77
Q

What may a pt with nasopalatine cyst present with

A

Swelling palatally over incisive canal

Discharge into nose or mouth

78
Q

Describe the radiographic appearance of nasopalatine cysts

A

Midline
Shape - round OR heart shaped due to superimposition of anterior nasal spine
Outline - well defined
Radiolucent

79
Q

Where are nasopalatine cysts found

A

In the midline of the anterior maxilla

80
Q

Effects of nasopalatine cysts

A

May displaced teeth if it is large

81
Q

Describe the lining of nasopalatine cysts

A

Pseudostratified columnar epithelium (Respiratory epi) or stratified squamous

82
Q

Describe nasolabial cysts

A

Non-odontogenic, soft tissue cyst arising in the nasolabial fold, upper buccal sulcus or lip

83
Q

Effects of nasolabial cyst

A

May erode bone of the anterior nasal apeture

84
Q

Lining of nasolabial cysts

A

Non-ciliated pseudostratified columnar, often rich in mucous cells (resp epithelium)

85
Q

When to biopsy a cyst

A
  • if the appearance is atypical for a cyst to confirm a diagnosis
  • If concerns of tumour or multilocular lesion that is likely to recur
  • Excisional biopsy as a definitive tx
86
Q

What may be aspirated out a cyst?

A
  • Clear/straw coloured fluid that shimmers = cholesterol crystals
  • Creamy viscous fluid = keratin therefore OKC
  • Creamy pus if infected
87
Q

What does tx of a cyst depend on?

A
  • Type of cyst
  • Presence of infection
  • Recurrence risk
  • Neoplastic change rate
  • Number of cysts present
  • Structures associated e.g. nerves, vessles, antrum
88
Q

Define enucleation

A

Removal of entire cyst (epi layer and capsular layer) from the bony cavity to ensure no pathological tissue remains

89
Q

Describe enucleation procedure

A

Large mucoperiosteal flap raised
Cyst peeled off bony cavity
Flush area with saline and suture
Specimen sent to lab for diagnosis

90
Q

Describe marsupialisation/decompression procedure

A
  • Window cut into soft tissue overlying cyst
  • Inner epithelium is sutured to outer epithelium
  • Cyst lining sutured to oral mucosa to keep it open
  • BIPP used to fill the cavity to prevent food accumulation
91
Q

Aims of marsupialisation

A

Reduce size of the cyst to relieve pressure via bone deposition at the base of the cavity

92
Q

Indications for marsupialisation

A

Large cyst whereby there is a risk of jaw fracture if eneculation is carried out
Associated structures at risk if enucleation carried out

93
Q

What is BIPP

A

Bismuth iodoform paraffin paste

94
Q

What may follow marsupialisation

A

Enucleation of the remaining cyst

95
Q

What are the types of excisions

A

Wide local excision

En bloc excision

96
Q

What is wide local excision

A

Removal of lesion with a margin of normal bone

97
Q

What is en bloc resection

A

Removal of a portion of a structure with a tumour

98
Q

Tx options for radicular cyst

A
  1. RCT alone
  2. RCT and enucleate
  3. RCT, apicectomy, retrograde root filling and enucleation
  4. extraction and enucleation
99
Q

Indications for rct alone for radicular cyst tx

A

Small radicular cysts only

100
Q

Review of pts after tx for radicular cysts

A

Low recurrence rate but monitor 3 months and 6 months for bony infill

101
Q

Tx of residual cysts

A
  • Enucleation very effective without risk of recurrence
102
Q

Tx of dentigerous cyst

A

Marsupialsation

May be followed by enucleation or excision

103
Q

Tx of nasopalatine cyst

A
  • Enucleation via palatal approach has a low recurrence rate
104
Q

What is sacrificed in nasoplatine cyst enucleation

A

The incisive nerve

105
Q

Tx of OKC

A
  • Enucleation with chemical fixative +/- peripheral ostectomy
  • Excision / resection
  • Marsupialisation
106
Q

Risk of simple enucleation with OKC

A

High recurrence due to satellite cysts within the fibrous wall and cancellous bone

107
Q

What does chemical fixative do

A

Necrosis of remnants

It hardens the cyst making it easier to remove

108
Q

Give an example of chemical fixative

A

Carnoy’s solution

109
Q

What tx options for OKC have the best results

A
  • Resection

- Enucleation, peripheral osteotomy and carnoy’s solution

110
Q

What is peripheral ostectomy

A

Drilling peripheral bone

111
Q

Monitoring of OKC

A

3/6/12 then annually

112
Q

Tx of lateral periodontal cyst

A

Buccal flap raised
Cutterage/enucleation
Remains tooth vitality

113
Q

Suspicious signs indicating tumour (not a cyst)

A
  • Recent onset of symptoms
  • Fast growing
  • Neuropathy
  • Resorption of adjacent structures
  • Lack of response to antibiotics or RCT

Oral Disease - Hard tissue (4 decks)

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